The commoditization of primary healthcare: A guide for health systems

noun com·mod·i·ty \kə-ˈmä-də-tē\ or com·mod·i·ti·za·tion \kə-ˌmä-də-tə-ˈzā-shən\ : A reasonably homogeneous good or material, bought and sold freely as an article of commerce.

With revolutionary changes in the healthcare industry brought about by the Affordable Care Act (ACA) and the shift from a Fee-for-Service to a Fee-for-Value ecosystem, primary and episodic healthcare is increasingly becoming a commoditized product. According to a recent Forbes article, there are over 10,000 privately run Urgent Care Centers operating in the United States; that equates to approximately 160 million visits annually. Moreover, industry journal Merchant Medicine indicates that CVS Health and Walgreens account for the lion's share of the over 1,800 Retail Health clinics that have launched in the U.S. in the last decade. That revolutionary growth in private retail and urgent care facilities and the threat they pose to the traditional primary care model should be a principal agenda item for many C-Suite and Hospital Boards. Just ten years ago, the number of these retail and urgent care clinics were negligible, as health systems and hospitals dominated the primary and episodic care ecosystem with appointment-based Physician practice locations and inefficient Emergency Rooms. Private retail competition and a paradigm shift to consumerism in patient preferences are now eroding health systems' primary care patient base and service area. To compete, health systems should create, execute, and manage a well thought-out ambulatory strategy.

Although health systems and hospitals continue to acquire physician practice sites to add to their Primary Care network, Modern Medicine reports that there has been a 10% drop in visits per week to Family Care Physicians since just 2013. This decrease seems counterintuitive with the vast increase in Americans who are now insured under the ACA. The data would indicate that patients are migrating for their care, and they are making their preferences known by voting with their feet. Instead of fearing this new standard, health systems should optimize their brand power to introduce their own consumer-focused strategy, opening Retail Walk-In clinics (run by Nurse Practitioners or in some cases Physician Assistants) or more comprehensive Urgent Care clinics (Physician led walk-in locations that are equipped with imaging and lab services) in locations where patients want them. But it takes more than putting up four walls and a logo sign to thrive. A "build it and they will come" philosophy will not be effective. Health systems should focus on ten key areas to attract and retain today's savvy healthcare consumers.

1. Launch centers in calculated, deliberate locations. Don't be fooled by brokers' claims or by locations that are primarily attractive because they seem like a good 'deal'. Start by doing your homework. Get traffic counts/patterns, demographics, and detailed population densities of the key markets in your service area. Once a general location area is targeted, use micro-level attributes such as street visibility, extreme proximity to primary care / specialty referral sites (i.e. orthopedics), and accessible parking are major keys to success. Because wayfaring signage is crucial, understanding local ordinances for signage is important in selecting the optimal site for the clinic.

2. Utilize the primary care network Physicians as true partners. Because many hospital-affiliated primary care physicians are feeling the blow of patients choosing private urgent care and retail healthcare clinics for illnesses and injuries, the physicians may be lukewarm to the new ambulatory ventures of a health system. By including and engaging key physicians in the strategy, a system can take that potential theme of disengagement and convert it into an appealing opportunity for its primary care network. In a recent study, The Convenient Care Association estimates that 40 percent of patients who show up at retail clinics do not have a primary care doctor. A thriving ambulatory care network can actually help to strengthen the existing primary care network if managed effectively.

3. Engage Managed Care providers early in the process. The peril that many retail and urgent care centers face a week before opening: not having fully-executed contracts in time for day one of launch. Making sure the Ambulatory team has managed care 'coverage' to the health system's service community for these clinics means amending existing hospital contracts or in many cases creating a carved-out independent contract between insurers and the clinics themselves. Imagine this scenario: a worried parent walks into the hospital-branded clinic with a child who has taken a tumble on the soccer field and has a possible broken bone. Because a contract hasn't been ratified or amended with the insurer that covers the child, the clinic cannot see the patient without charging a full cash price for the visit (most clinics have a published cash price for those patients that are either uninsured, are from another country, or are willing to pay cash if there is no contract with their insurer). Parents in this scenario will almost always walk out the door and choose the myriad of other options in the area; and probably won't ever return. It is vital to concurrently work on garnering relationships with the payers and perform insurer-mandated due diligence like schedule walkthroughs well ahead of a scheduled launch date.

4. Build and construct centers for comfort & efficient patient flow. Ideas such as handheld devices that buzz when a patient is ready to be seen, Zen-like post-procedure waiting areas tucked away within the center, or very snappy check out processes should be vetted and be part of the design process. With convenience and comfort becoming increasingly important to consumers, a system will not get a second chance to recreate an appealing environment for patients to enter, be seen, treated, and exit. Speaking of comfort, this should be at the forefront of every decision when designing key patient space within the clinic. Systems should consider things like what the patient may initially see when entering the clinic or patient room or even from the exam table itself. Don't underestimate the importance of seemingly minor details in the patient's experience.

5. Execute the patient flow design to create convenience and access; a prevailing attribute for a commoditized service. In a recent Advisory Board 2015 survey, respondents were asked questions assuming they had the flu and their typical provider was unavailable. Walking into an office without any appointment and waiting more than 30 minutes was the #1 ranked attribute in the survey. Five of the next nine attributes dealt with either access or convenience. How do you respond to this emerging expectation when most patients will create a backlog of volume by visiting your future center early in the AM, right after the workday, or in the evening prior to 8:00 pm? Take a page from other retailers and mitigate patient check-in difficulties by providing online registration and utilizing built in protocols and procedures to get patients seen and treated within 30 minutes no matter what the bottleneck of patients. Just like IT developers test the data flow of the visit within the EMR, it behooves the team to physically role-play the patient experience from entering the facility to checking out. By determining steps in the process that may not make sense or that seem counterintuitive, steps in the process can be refined for a highly-efficient visit for patients.

6. Create a cross-functional marketing plan to lure both the senior & smartphone community. Often times, healthcare and more specifically population health now involves managing groups of patients into risk categories. Each cohort has seeks healthcare uniquely; so marketing plans must be diverse and iterative. The low-risk patient, an otherwise healthy Millennial for instance, which is often overlooked by hospital marketing machines (and subsequently catered to by private competition) represents almost 75% of patients who are healthy or may have a well-managed chronic condition. Research indicates they, like many younger consumers, prioritize convenience over other traditional attributes; health systems and hospitals must react accordingly. To cater to these patients, health systems should focus on things like web-based smartphone technology. That may mean something as simple as creating the web landing page with smartphone-friendly visuals to allow easy check-in via an app. For the "rising-risk patient" which may skew a little older but still represents a significant portion of the population, some marketing tweaks may need to occur. Advisory Board states that perhaps only 36% of this group have a PCP; which is still a prime opportunity for health systems. This population may need more traditional marketing vehicles to gain attention. For instance billboards and data-driven direct mailers should be budgeted for in order to capture and regain this patient from competitors.

7. Staff judiciously and utilize all of your clinical team to their fullest abilities. Assembling the right team members is not unlike selecting the right geographic location for clinics in that there is no silver bullet for success. Health systems should be patient and thorough when hiring every member of the team. Several questions should be answered: Does the Physician understand the importance of quick yet effective visits? Do team members know that working weekends and late evenings is part of the expectation? Should the Physician team consist of Emergency Room Physicians? Whatever is decided remember to maximize the clinical care of each support member and ensure the team is comfortable performing all tasks. This "comfortability-training" will instill patient satisfaction that is many times overlooked.

8. Engaging patients starts with engaging colleagues. Most leadership teams in health systems and hospitals understand how important mastering patient engagement is to patient loyalty. The first line of defense against patient disengagement is the clinics' colleagues themselves. Systems must create a team-based atmosphere that includes all: Clinic Physician, Nurse, Medical Assistant, Radiology Technologist (in Urgent Care Centers) and non-clinical support staff and stakeholders (for instance couriers picking up samples). Stimulating camaraderie among the team will lead to consistent messaging to patients, indicate confidence in the treatment, and increase productivity.

9. Engaging patients continues after they leave and should not be a 'check the box' culture. It's easy to focus on patient engagement only during the point of care portion of the visit. It is important from a cultural standpoint to promote patient experience in the ambulatory setting after a patient leaves as well. This practice should be in place because it is the 'right' thing to do for patients; not just to raise HCAHPS scores. HCAHPS refers to Hospital Consumer Assessment of Healthcare Providers and Systems survey which is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. At a minimum, the Ambulatory team should ensure things like prescriptions are filled accurately and perform or outsource callback policies for all patients seen.

10. Create robust internal referral protocols and monitor closely. What is the key of all of this hard work? Downstream patient volume, patient loyalty, and ability to manage 'healthy' patients throughout their lives. How does a health system attain this successful outcome? By creating complete ease for patients to see specialists (Orthopedics, Dermatology, and Imaging) within the health system's ecosystem directly after the clinic visit. It is important to design this system before opening the ambulatory care center's doors. It could entail slick IT requirements and network optimization. Normally, however, this referral system features good old-fashioned written-to and adhered-to policy and procedure. Of course, hospitals and health systems should spend the time to work with IT to connect EMR functionality throughout the system; but leadership should dedicate ample funds and time to working on linking in with customer care centers to make vital follow-up appointments for patients on their behalf.

Many experienced healthcare leaders in hospital settings are not accustomed to comparing and contrasting their next move with successful retailers like Starbucks, Target, or even Wal-Mart. Clearly however, the same types of careful considerations that these wildly successful companies have undertaken must be considered for the quickly-evolving ambulatory healthcare world. Creating accessible, convenient, and effective healthcare on the corner of "main and main" will help health systems and their hospitals differentiate themselves from competitors and delight patients in this latest industry to enter the world of commoditization.

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